Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01764-143 | Comprehensive Healthcare Inspection Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors compliance.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors at the Alvin C. York campus consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
Closure Date:
3 The Facility Director ensures clinicians document patient education for patients receiving anticoagulation medication and monitors compliance.
Closure Date:
4 The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee and monitors compliance.
Closure Date:
5 The Chief of Staff ensures providers consistently document patient or surrogate informed consent and the patient’s medical and behavior stability when patients are transferred out of the facility and monitors the providers’ compliance.
Closure Date:
6 The Chief of Staff ensures providers countersign the acceptable designees’ transfer/progress notes when patients are transferred out of the facility and monitors compliance.
Closure Date:
7 The Associate Director ensures that environment of care rounds are conducted at the required frequency and correctly documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
8 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
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9 The Associate Director ensures ventilation grills are clean and ceiling tiles are properly maintained and monitors compliance.
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10 The Chief of Staff ensures radiation safety signage is posted in each radiation area and monitors compliance.
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11 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
12 The Associate Director ensures all mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
13 The Chief of Staff ensures that providers include review of abnormalities of major organ systems in the history and physical exams and/or pre-sedation assessments and monitors compliance.
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14 The Chief of Staff ensures that providers inform patients when the provider performing a moderate sedation procedure is not the provider listed on the informed consent for the procedure and document the patient’s assent to the change and monitors compliance.
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15 The Chief of Staff ensures clinical employees who perform, assist with, or supervise moderate sedation procedures have current moderate sedation training and monitors their compliance.
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| 15-04678-114 | Review of Alleged Hazardous Construction Conditions at the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma | Audit | ||
1 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure contracting officer’s representatives comply with duties assigned in the Delegation of Authority Memo.
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2 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure that on future contracts, the Chief, Engineering Service, assign contracting officer’s representatives who have experience commensurate with delegated responsibilities in accordance with the Federal Acquisition Regulation.
Closure Date:
3 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure personnel follow established Veterans Health Administration policies on safety inspections.
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4 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, clarify the implementation of the safety inspections in Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017, to ensure the safety inspections are not performed routinely or in a discernable pattern.
Closure Date:
5 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure the assignment of a safety officer in accordance with Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017.
Closure Date:
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| 17-05402-137 | Comprehensive Healthcare Inspection Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors members’ compliance.
Closure Date:
2 The Chief of Staff ensures the Infection Prevention Committee consistently documents discussions of the high-risk elements and analysis of surveillance data and monitors compliance.
Closure Date:
3 The Facility Director ensures that 1-day reconciliation of controlled substance refills to automated dispensing units in patient care areas and 1-day reconciliation of returns to pharmacy stock are performed consistently during controlled substance inspections, and the Facility Director monitors compliance.
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4 The Facility Director ensures that 72-hour pharmacy inventories are consistently completed during controlled substance inspections in pharmacy areas and monitors compliance.
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5 The Chief of Staff ensures that the geriatric evaluation program receives the required oversight and that quality improvement data are regularly reviewed and documented in committee minutes, and the Chief of Staff monitors compliance.
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6 The Chief of Staff ensures that geriatric evaluation program registered nurses perform the required patient assessments and monitors the nurses’ compliance.
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7 The Chief of Staff ensures ordering providers or designees communicate mammogram results to patients within the required timeframe and monitors providers’ compliance.
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| 17-00753-78 | Audit of the Personnel Suitability Program | Audit | ||
1 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness implement the monitoring program required by policy and establish robust management oversight of the personnel suitability program.
Closure Date:
2 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness report the results of program monitoring activities and obtain corrective action plans from the Veterans Health Administration.
Closure Date:
3 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness establish and enforce quality and performance metrics for the personnel suitability program.
Closure Date:
4 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness evaluate human capital needs for program oversight and facilitate the delegation or brokering of duties necessary to manage the background investigation workload.
Closure Date:
5 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness coordinate with the Executive in Charge, Office of the Under Secretary for Health, to implement a plan to review the suitability status of all Veterans Health Administration personnel and correct delinquencies to ensure a properly vetted workforce.
Closure Date:
6 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, improve management oversight of the personnel suitability program at VA medical facilities and ensure background investigations are properly initiated and adjudicated nationwide, and internal control mechanisms required by policy are properly implemented.
Closure Date:
7 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, execute VA requirements to improve the governance of the personnel suitability program.
Closure Date:
8 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, evaluate human capital needs and coordinate appropriate resources to manage personnel suitability workload at VA medical facilities.
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9 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness develop and execute a project management plan to ensure sufficient and appropriate data are collected in support of suitability program objectives.
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10 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness ensure that personnel suitability investigation data are fully evaluated and reliable for program tracking and oversight.
Closure Date:
11 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, coordinate with the Assistant Secretary for Operations, Security, and Preparedness to implement a plan to correct current data integrity issues and improve the accuracy of personnel suitability program data.
Closure Date:
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| 17-00253-102 | VHA Review of Selected Construction Projects at Oklahoma City VA Health Care System | Audit | ||
1 The OIG recommended the Acting Under Secretary for Health ensure the construction areas in the Surgical Intensive Care Unit project are sealed to prevent further weather damage.
Closure Date:
2 The OIG recommended the Acting Under Secretary for Health ensure the Oklahoma City VA Health Care System implements procedures to strengthen minor and non-recurring maintenance construction oversight.
Closure Date:
3 The OIG recommended the Acting Under Secretary for Health determine if administrative actions should be taken concerning key officials responsible for the Surgical Intensive Care Unit project.
Closure Date:
4 The OIG recommended the Acting Under Secretary for Health ensure the Oklahoma City VA Health Care System establishes procedures to ensure recommendations by technical experts, who perform site visits to evaluate project completion status and conformance to contract specifications as provided in design and construction contracts, are implemented.
Closure Date:
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| 17-01761-129 | Comprehensive Healthcare Inspection Program Review of the Providence VA Medical Center, Providence, Rhode Island | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data quarterly and monitors the managers’ compliance.
Closure Date:
2 The Facility Director ensures the Patient Safety Manager conducts the minimum of four individual root cause analyses each year and monitors compliance.
Closure Date:
3 The Facility Director ensures the Patient Safety Manager prepares and submits annual patient safety reports and monitors the Patient Safety Manager’s compliance.
Closure Date:
4 The Chief of Staff ensures inter-facility patient transfer data are collected and analyzed as part of the facility’s quality management program and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that staff/attending physicians countersign transfer notes written by acceptable designees for patients transferring to another facility and monitors physicians’ compliance.
Closure Date:
6 The Chief of Staff ensures that facility staff consistently document provision of necessary medical care within the facility’s capacity for all patients prior to transfer to another facility and monitors staff compliance.
Closure Date:
7 The Chief of Staff ensures Radiology Service employees check the emergency cart and defibrillator according to facility policy and monitors compliance.
Closure Date:
8 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
9 The Associate Director ensures all members of the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors members’ compliance.
Closure Date:
10 The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates the CNH program into the facility’s quality improvement program, and the Chief of Staff monitors the committee’s compliance.
Closure Date:
11 The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and monitors the team’s compliance.
Closure Date:
12 The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitors social workers’ and registered nurses’ compliance.
Closure Date:
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| 17-01854-115 | Comprehensive Healthcare Inspection Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
Closure Date:
2 The Facility Director ensures inter-facility patient transfer data are collected and reported to the Medical Executive Committee and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include documentation of patient or surrogate informed consent and identification of transferring and receiving provider or designee in transfer documentation and monitors the clinicians’ compliance.
Closure Date:
4 The Chief of Staff ensures that transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitors acceptable designees’ compliance.
Closure Date:
5 The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors providers’ compliance.
Closure Date:
6 The Deputy Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
Closure Date:
7 The Deputy Director ensures core team members consistently attend environment of care rounds and monitors compliance.
Closure Date:
8 The Deputy Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
9 The Chief of Staff ensures staff who perform, assist with, or supervise moderate sedation procedures have current Talent Management System moderate sedation training and monitors their compliance.
Closure Date:
10 The Associate Director for Patient Care Services ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors the social workers’ and registered nurses’ compliance.
Closure Date:
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| 16-04655-70 | Audit of VISN 7 Power Wheelchair and Scooter Repairs | Audit | ||
1 The OIG recommended the Veterans Integrated Service Network 7 Director require VA medical facility staff to input power wheelchair and scooter repair requests as soon as they are received and implement management controls to ensure repairs with closed consults are monitored to completion.
Closure Date:
2 The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service staff follow documentation procedures by making annotations in the consults as required by Veterans Health Administration Directive 1232(1), Consult Processes and Procedures, and the Prosthetic and Sensory Aids Service Business Practice Guidelines for Prosthetics Consult Management for power wheelchair and scooter repair.
Closure Date:
3 The OIG recommended the Veterans Integrated Service Network 7 Director implement controls to ensure Prosthetic Service staff monitor and follow up on repairs from initial request through completion to ensure the repairs are timely.
Closure Date:
4 The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service managers and staff monitor vendors to ensure they meet agreed-upon delivery dates for repairs.
Closure Date:
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| 17-00481-117 | Audit of Veteran Wait Time Data, Choice Access, and Consult Management in VISN 15 | Audit | ||
1 The OIG recommended the Veterans Integrated Service Network 15 Director ensure that staff at all network facilities use the clinically indicated date, when available, when scheduling new patient appointments.
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2 The OIG recommended the Veterans Health Administration Executive in Charge initiate a process to automate the use of the clinically indicated date, when applicable, when scheduling appointments.
Closure Date:
3 The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities appropriately manage the scheduler audit tool in order to conduct the required scheduler audits, communicate specific audit results to scheduling staff, and take corrective actions as needed based on audit results.
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4 The OIG recommended the Veterans Integrated Service Network 15 Director examine processes to improve monitoring and tracking for timely surveillance colonoscopies.
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5 The OIG recommended the Veterans Integrated Service Network 15 Director implement additional standard monitoring procedures sufficient to enable network facility staff to accurately manage the aging of all referrals for eligible veterans for Choice care.
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6 The OIG recommended the Veterans Health Administration Executive in Charge implement standard monitoring procedures to ensure medical appointment timeliness standards are met as required under Choice contracts.
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7 The OIG recommended the Veterans Health Administration Executive in Charge implement controls to ensure Choice medical documentation is received timely in accordance with Choice contracts.
Closure Date:
8 The OIG recommended the Veterans Integrated Service Network 15 Director communicate specific audit results of VHA’s audit of consults to all network facility staff involved in consult management, implement specific training, and ensure corrective action is taken as needed.
Closure Date:
9 The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities manage consults that are clinically indicated for the future in accordance with VHA’s consult policy.
Closure Date:
10 The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities implement contingency plans in accordance with VHA’s outpatient clinic practice management policy and communicate to providers regarding how to process consults when a service becomes unavailable.
Closure Date:
11 The OIG recommended the Veterans Integrated Service Network 15 Director ensure the care of patients identified in the patient summaries of this report are evaluated, take action, if appropriate, and confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
Closure Date:
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| 17-01485-128 | Healthcare Inspection – Mismanagement of Resuscitation and Other Concerns at the Buffalo VA Medical Center, Buffalo, New York | Hotline Healthcare Inspection | ||
1 We recommended that the VA Office of the General Counsel, pursuant to VA Directive 6311, work in conjunction with the Office of Information Technology, Veterans Health Administration offices, and other interested offices to advise the Under Secretary for Health regarding the refinement (or development) of policies reasonably designed to ensure the preservation of electronically stored information when legally necessary (or desirable for purposes of quality improvement), including, but not limited to electronically stored information that is subject to auto-deletion, such as telemetry data.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director conduct an evaluation of the Facility’s quality management practices (including but not limited to Root Cause Analyses, Issue Briefs, Administrative Investigation Boards, and Institutional Disclosures) to ensure that they align with Veterans Health Administration policies and also address the following specific deficiencies in this case: (a) the failure to conduct a Root Cause Analysis, (b) the failure to conduct a timely Administrative Investigation Board, (c) the failure to provide an Issue Brief, (d) the failure of the Administrative Investigation Board to consider all available evidence, and (e) the failure to make an Institutional Disclosure consistent with Veterans Health Administration Policy.
Closure Date:
3 We recommended that the Facility Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
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4 We recommended that the Facility Director ensure that staff conduct interprofessional mock code training throughout the Facility with debriefing and monitor outcomes.
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5 We recommended that the Facility Director conduct an evaluation inclusive of, but not limited to, unit 9B and the Respiratory Department to determine if there are issues undermining teamwork at the work place, take action to address those issues, and monitor compliance.
Closure Date:
6 We recommended that the Facility Director ensure that staff adhere to the Facility’s telemetry policy including, but not limited to, saving rhythm strips when a patient has a change in his/her baseline or a significant arrhythmia, that a competent staff member is always at the telemetry station, and that facility managers monitor compliance.
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7 We recommended that the Facility Director ensure that the Facility’s Education Department staff review the adequacy of its annual telemetry monitoring re-certification process including, but not limited to, evaluating whether to institute additional requirements for staff who rarely have practical experience in telemetry monitoring and establishing procedures to ensure that re-tests are conducted and tracked appropriately and monitor compliance.
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8 We recommended that the Facility Director evaluate the Respiratory Department handoff communications process including the timing of patients’ treatments and code status and modify as appropriate.
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9 We recommended that the Facility Director ensure staff assess patients before and after breathing treatments, document the patient’s response in the electronic health record, and monitor compliance.
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10 We recommended that the Facility Director review the content of Facility staff’s communication to the patient’s family and take corrective action if it is determined that the communication was insufficient to convey that the Facility was disclosing potentially inadequate care.
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